'Violence is immoral because it thrives on hatred rather than love... violence ends up defeating itself. It creates bitterness in the survivors and brutality in the destroyers' - Martin Luther King Jr (1964)
The life of every domestic abuse survivor is somewhat altered due to the aftermath of such a harrowing experience. When exiting from an abusive relationship, it is important to remember the transition from being an individual who was once controlled by another human being, to then becoming someone who is back in control of there own life, is a very challenging one (Anderson, Renner & Danis, 2012). The shift between these two mental states involves remarkable strength and courage as for the first time, the prospect of building a new life is future envisioned rather than undergoing the struggle of everyday survival (Senter & Caldwell, 2002).
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Domestic abuse covers many aspects of extreme physical, mental, sexual and emotional abuse that often impacts a victim not only at the time of an assault but also for many years after the incident(s) have occurred. Due to the relentless cruelty of domestic abuse, the lasting consequences have been reported to potentially cause an individual to develop mental health problems such as depression, suicidal ideation, post-traumatic stress disorder (PTSD) (Fergusson, Horwood, & Ridder, 2005; Jones, Hughes, & Unterstaller, 2001; Mechanic, Weaver, & Resick, 2008), as well as issues with substance misuse (Jones, Hughes, & Unterstaller, 2001; Waldrop & Resick, 1993) amongst many other physical and mental health concerns (Arias, Harper & Straight, 2003).
The following literature review is going to specifically analyse the previous literature on the link between posttraumatic stress disorder and domestic abuse.
Childhood Abuse (Trauma) and PTSD Symptoms
The connection between childhood abuse (trauma) and men’s abuse of women has been clearly established within reviewed literature (Connolly et al., 2006; Cunningham & Baker, 2004; Edleson, 1999; Guille, 2004; Hester et al., 2000; Holt, Buckley & Whelan, 2008). The implications on a child’s emotional and mental state when witnessing parental domestic abuse can be somewhat considered as a form of emotional abuse in itself. In turn, this could have potential negative implications on any future adult relationships. (Brandon & Lewis, 1996; Holt, Buckley & Whelan, 2008).
The classification of a direct observation of abuse/violence can include that of the direct witnessing of both violent sexual and physical assaults towards their mother, as well as the on-going consistency of the nature of the abuse over a period of time. From analysis of 48 mothers and 54 children, McGee’s (2000) research found that 71% of the 54 children witnessed some form of physical abuse towards their mother. This included 10% bearing witness to the rape of their mother (Holt, Buckley & Whelan, 2008). McCloskey, Figuerdo, and Koss found similar findings when using a significantly greater sample of 365 women and 365 children in 1995. When interviewed, two-thirds of the women disclosed choking was carried out during their physical assaults with just fewer than 50% of the children reporting the witnessing of such abuse towards their mother (Holt, Buckley & Whelan, 2008). Previous research on a child’s exposure to sexual abuse towards their mother shows increased distress and trauma from this type of experience (Holt, Buckley & Whelan, 2008; Weinhall, 1997, cited in Hester et al., 2000). Kilpatrick and Williams (1998) however, conducted a smaller study that consisted of 35 mothers and their children. Their findings found that in relation to the intensity and frequency of abuse within the home, the significance of neither intensity nor the frequency predicted any symptoms of post-traumatic stress in the children. Their study concluded that ‘domestic violence has the capacity to provoke trauma in the child, regardless of frequency or intensity’ (Kilpatrick and Williams, 1998).
In households where there is domestic violence present, it has been established that the quality and ability of both parents supporting their child’s needs are compromised (Buchbinder, 2004; Holt, Buckley & Whelan, 2008; Levendosky & Graham-Bermann, 2001; McIntosh, 2002; Mullender et al., 2002). It can be indicated that due to this compromise there can become a lack of attachment between mother and child (Cleaver et al., 1999; Holt, Buckley & Whelan, 2008; Levendosky, Huth-Bocks, Shapiro, & Semel, 2003). Literature suggests that children of pre school age who have been witness to violence or abuse within the home, have increased problems with behaviour, social problems, difficulty with showing empathy, as well as prominent post-traumatic stress symptoms than those who have witnessed no form of violence or abuse (Rossman, 1998; Holt, Buckley & Whelan, 2008; Huth-Bock, Levendosky & Semel, 2001). Reviewed literature supports this finding as it has been suggested that insecure attachments heighten vulnerability to the symptoms of PTSD compared to secure attachments developed in childhood (Ogle, Rubin & Siegler, 2015).
It has been suggested that children who have been exposed to violence/abuse within the childhood home are more likely to develop relationships that are violent or abusive within adulthood. Copied or learnt behaviour of children by their parents is detrimental to this as it has become evident within previous literature that boys learn much of their behaviours from their fathers for example, violence towards women. Nonetheless in contrast, girls are likely to learn behaviours from there mothers such as violence being normalised within the home and violent acts and abusive behaviours being somewhat expected from their partners (Royal College of Psychiatrists, 2019).
Despite these suggestions however, it is important to remember not all children replicate the same patterns of behaviour as their parents within adulthood. As a child, violence and abuse can become a behaviour to which a child will try very hard to not replicate due to the witnessing of the after effects of such trauma to their loved ones. Nevertheless, this doesn’t mean the after effect of domestic violence/abuse doesn’t impact a child’s future, particularly in relation to the symptomology of PTSD (Royal College of Psychiatrists, 2019).
Adulthood Domestic Abuse
Domestic abuse in adulthood is similar to that of child abuse. It enables an abuser into a position of control and power that allows them to target the person whom they deem has less power in the relationship. As previously discussed, regardless of sexual preference or gender, children who have been exposed to violence/abuse are more likely to become abusive in their own future relationships within adulthood.
Lenore Walker's theory of ‘The Cycle of Abuse’ provides an understanding of why this may be, alongside offering an explanation as to why many victims of domestic violence/abuse often develop symptoms of posttraumatic stress disorder. Previous literature has shown that individuals who suffer from posttraumatic stress disorder can be drawn towards situations of violence. This enables the cycle of abuse to potentially repeat itself from generation to generation. The cycle of abuse allows exposure to the traumatic assaults to re-run on a continuous cycle for the victim, which can in turn cause long-term psychological stress in the on-set of PTSD (Babbel, 2019).
Posttraumatic stress disorder can be best described as a psychiatric disorder that can occur when a person has witnessed or experienced a traumatic event such as a serious assault, a natural disaster, a terrorist act, rape, war/combat or domestic abuse. It can cause people to have intrusive thoughts and intense feelings that are related to their distressing experience. This can occur in the initial stage after an event or alternatively, continue long after the traumatic experience has past. Flashbacks and nightmares are often reported which causes an individual to relive the trauma all over again. This can leave an individual feeling a mix of emotions from sadness, anger and fear as well as feelings of isolation and detachment from others (American Psychiatric Association, 2019). The National Center on PTSD (2019) suggested that women are of a higher probability of suffering from trauma, which includes that of domestic violence. It has been reported that women have a 10% chance of developing the disorder, whereas men are reported to stand at only a 4% chance.
Despite traumatic responses varying from one person to another, Jones, Hughes, & Unterstaller (2001) suggest a significant percentage of domestic abuse survivors (31% to 84%) demonstrate PTSD symptoms. Previous literature on women’s shelters has found that women living within these shelters have a higher occurrence of violence and abuse than abused women who are not homed within shelters (Gondolf & Fisher, 1998; Perez, Johnson & Wright, 2012). Due to this, women victims of domestic violence who do live in shelters, are also more likely to show increased rates of violence related PTSD (Jones et al., 2001; Kemp, Rawlings, & Green, 1991; Perez, Johnson & Wright, 2012; Saunders, 1994).
Prior research suggests that the symptoms of PTSD in relation to domestic abuse can interfere with a victim’s effective use of resources (Johnson, Zlotnick, & Perez, 2008; Krause, Kaltman, Goodman, & Dutton, 2008; Perez & Johnson, 2008; Perez, Johnson & Wright, 2012). The Conservation of resource theory (Hobfoll & Lilly, 1993) theorises that the loss of both material and personal resources offers a key part in relation to stress reactions, which also includes PTSD. Domestic abuse often risks the loss of resources for example, financial security, appropriate and safe housing as well as other basic life requirements (Roberts & Burman, 2007; Perez, Johnson & Wright, 2012; Sullivan & Gillum, 2001). For victims tormented by the symptoms of PTSD, this potential loss of resource has been related, in previous literature, to a rise in symptoms of mental health issues predominantly that of PTSD (Hobfoll, 1989; Perez, Johnson & Wright, 2012).
Kemp, Green, Hovanitz, and Rawlings (1995) examined 179 battered women and 48 female survivors in a community-based, shelter sample. This sample was a first of its kind as it was one of the original studies to examine forms of domestic abuse rather than abuse as a whole. The study examined psychological abuse aside from physical violence in relation to PTSD. Kemp, Green, Hovanitz and Rawlings (1995) outlined the definition of battered women as those whom had experienced a form of physical violence that stretched from a mere push to extreme physical acts such as attempted murder. 81% of the sampled battered women hit the criteria for a diagnosis of PTSD together with the sampled psychologically abused women matching the criteria at 62.5% for a diagnosis (R. Tramayne, 2012). Interestingly however, although it has been well documented within previous literature the link between physical violence/trauma and PTSD, Taft, Murphy, King, Dedeyn, and Musser (2005) found within their research that there was a stronger link to PTSD symptomatology in relation to psychological abuse than that of physical abuse (R. Tramayne, 2012). Although a relatively new topic of research, it is believed there may be a stronger connection between domestic psychological abuse and PTSD than that of physical trauma and abuse (South African College of Applied Psychology, 2018).
PTSD: Psychological abuse vs. physical abuse
Psychological abuse is one of the most frequent forms of abuse used by perpetrators as it often the hardest to spot from a victim. With the lack of visible signs that is common with physical abuse, it is often meant that the psychological abuse a victim will endure can potentially go unnoticed for years (Tracy, 2019).
The impact of psychological abuse can be just as destructive as abuse that is physical however, the difference psychological abuse has over physical abuse is that it can affect a persons feelings and thoughts whilst having full control of a persons everyday life. Psychological abuse has the potential to devastate any form of relationship from friendships to intimate relationships. One of the biggest impacts however is that of someone’s self esteem and belief in themselves being utterly destroyed (Tracy, 2019).
On the other hand, physical abuse frequently transpires besides other kinds of abuse such as emotional abuse, sexual abuse and even financial control. To define physical abuse, the New York State Office of Children and Family Services (2019) states ‘'Non-accidental use of force that results in bodily injury, pain, or impairment. This includes, but is not limited to, being slapped, burned, cut, bruised or improperly physically restrained”. Physical abuse is often used to overpower and gain control over another person (Tracy, 2019).
In 1979, Walker (2005) identified that battered women who partook within his study, suggested that the psychological abuse that they had been subjected to, was far more harmful than the physical abuse they had previously endured. Similarly, Follingstad et al (1990) has reported this finding in more up to date quantitative research. Follingstad et al (1990) stated that 72% of their women sample, who had been previously physically abused, recalled that the psychological abuse they had experienced had had a more detrimental effect on them than the abuse they endured physically by there abuser. Intriguingly, those women who had testified to the psychological abuse being more negatively impacting did not vary very much from the remaining sample in regard to the frequency of the physical abuse or the severity of the physical incidents (Street & Arias, 2001). Sackett and Saunders (1999) found similarly that, from the battered women who were seeking help from support services, the psychological abuse was a greater predictor of the women's fear than that of the physical abuse. This discovery is highly significant as fear during/from a traumatic event, has previously been distinguished as a compelling factor in the development of Post Traumatic Stress Disorder (Briere, 2004; Street & Arias, 2001).
Treatment for PTSD with Victims of Domestic Abuse
Despite PTSD having a strong link to victims of domestic abuse, it was surprising to find so little literature and research covering effective treatments for victims suffering from such a distressing disorder in relation to the discussed topic.
It is well published that treatments already exist for individuals in the aftermath of trauma and PTSD, yet the treatments available do not offer victims of domestic abuse the stability to not fear the risk of revictimisation. It has been suggested that the primary focus of treatment in relation to PTSD in victims of domestic abuse is that it needs to be consistent and coincide with the victim’s current and ever changing needs.
The most common and documented form of treatment used to help individuals suffering with PTSD would be that of exposure to the trauma however, understandably this would not be suitable in line with the support needed for domestic abuse victims (Perez, Johnson & Wright, 2012). Jaycox & Foa (1996) reported that the effectiveness of exposure based treatments offered to domestic abuse victims was somewhat tainted due to the on-going struggle of intense anxiety. Domestic abuse often already inflicts high levels of anxiety in individuals that in turn, can trigger fear responses towards the menace of continuing victimisation (Foa, Cascardi, Zoellner, & Feeny, 2000; Perez, Johnson & Wright, 2012). According to previous literature, due to the trepidations of victimisation, interventions, which offer exposure to trauma, can be seen as ineffective due to running the risk of traumatising the victims further. Consequently, it has to be perceived that traditional treatments of PTSD that encompass a form of exposure are not suitable for this area of trauma (Perez, Johnson & Wright, 2012).
On the other hand, Johnson, Zlotnick, and Perez (2011) created a new cognitive behavioural treatment, which was shaped by Herman (1992) called ‘Helping to Overcome PTSD through Empowerment’. The ‘multi-stage model of recovery’ was aimed at addressing the demand for PTSD treatment in domestic victim shelters. It envisions recovery from persistent trauma as transpiring in 3 phases: (1) establishing safety, (2) mourning and resemblance and (3) reconnection (Klostermann, 2015). It has been established that ‘Helping to Overcome PTSD through Empowerment’ is an effective therapy due to its prominence on elements such as stabilisation and safety. For those suffering from PTSD due to domestic trauma, it is paramount to get to a setting and feeling of physical safety as well as having accessibility to resources that will assist with refining a stable and safe life filled with quality moving forward. ‘Helping to Overcome PTSD through Empowerment’ incorporates Herman’s phase approach outlined with a cognitive behaviour view. This includes various components of traditional Cognitive Behavioural Therapy for PTSD for example, skill building and cognitive restructuring. Previous literature advises that sufferers of PTSD manage trauma built on their prior belief on others, ones self and everything else around them (Ehlers & Clark, 2000; Klostermann, 2015; McCann, Sakheim, Abrahamson, 1988). This ‘cognitive restructuring’ contributes to the symptoms of PTSD as it produces an amplified sense of an existing threat. The dysfunctional strategies for coping and negative emotions can potentially act as a sequence in upholding the PTSD symptoms. This is why individuals are endlessly advised through the model to identify any threats which are deemed as controllable to their emotional and physical wellbeing as well as making the clear use of their tools of empowerment to control any potential threats (Klostermann, 2015).
Conclusion
The link between Post Traumatic Stress Disorder and domestic abuse can be described as a very complex one. It is evident that individuals who have experienced domestic abuse hold a higher risk of developing posttraumatic stress disorder however; those who suffer posttraumatic stress disorder are more likely to engage in forms of domestic abuse. Research has identified that there are available approaches to treatment, which are deemed as effective in relation to domestic abuse posttraumatic stress disorder.
Whilst there is extensive research relating to PTSD and domestic abuse individually, it is clear that more research needs to be done in relation to the two topics together and in particular form of integrative treatment.
This is an area of devastating trauma that needs continuous reevaluation and attention due to the ever-changing epidemic of mental health in today society. “Trauma is hell on earth. Trauma resolved is a gift from the gods.” - Peter A. Levine (2012)
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